P. REISSMAN Laparoscopic hand assisted subtotal pancreatectomy

Good morning and welcome in Rome.

Here is Dr. Arbiton, and I wanted to present you our case of laparoscopic hand-assisted pancreatectomy.

There's some technical problem.

Do you see a presentation?

Yes, sir.

So we started with the section of a lot of adhesions in the abdomen after previous multiple operations.

Here you'll see the – after the adhesives were divided, the splenic fascia was mobilized

and the lesser saccantara through the gastrocolic ligament.

Here is a tumor at the tail of the pancreas – or the body of the pancreas, exactly.

The window in the gastrocolic ligament was enlarged in order to expose the entire pancreas.

Here the pancreas, we started with dissection of the pancreatic tail.

This is a bed of the pancreas, and we are proceeding in the direction of the head of

the pancreas.

We are holding the pancreas with the left hand.

This is splenic vein, splenic artery.

The gastropancreatic ligament is dissected in order to reach the celiac trunk, and one

of the lymph nodes from the celiac trunk was sent to pathology and turned to be a reactive

lymph node.

We continue to dissect the pancreas of the retroperitoneal and of the aorta.

Here is the aorta.

This is a pancreas which was already mobilized with a spleen connected to its tail.

Here we start with the section of the splenic vein close to its confluence with the superior mesenteric vein.

You'll see it a bit later.

splenic artery is dissected its origin from the celiac trunk and GIA white cartridge vascular endo

GIA was applied and the splenic artery is cut its its origin from the splenic from the celiac

trunk here you see the left gastric artery and coronary vein celiac trunk we did the

an intraoperative laparoscopic ultrasound to see what's an extension of this tumor to

the direction of the head of the pancreas. It turned to be that we have a clear cut of

the tumor in the pancreatic body. Therefore, we proceeded to the section. Here you can

see splenic vein, the stump of the splenic artery, excuse me, and the hepatic artery

here. We accomplish the dissection. This is portal vein, splenic vein, superior mesenteric vein.

We continue with the dissection of the splenic vein. This is a stamp of the pancreas and we

continue to dissect and to do the lymph node dissection along the hepatic artery. The dissection

is accomplished and the pancreas was cut with the laparoscopic and the GIA. Again, with wide

cartridge. We prefer to use vascular endo-GIA. We continue the dissection in order to get

the obviously clear margins of our resection of the pancreas. This is a tumor. See the

anatomy, common hepatic artery, gastro-duodenal artery, portal vein. Now the endo-GIA is applied

to the pancreas, at the head of the pancreas, small part of the pancreas. The specimen is

inserted in the endo bag and retrieved note you can see this is a specimen this is a pancreatic

tail with a spleen here and you'll see there are some centimeter and a half from the cut margin

and the tumor here this is a final picture you can see here the common hepatic artery this is

a heart and the celiac trunk this is a stamp of the splenic artery splenic vein is cut at its

its origin of its confluence with superior mesenteric and portal vein here is a small

branch of coronary vein we cutted it during the section stamp of the pancreas is here

and again the stamp of the splenic artery left gastric artery clip on the stamp of the coronary

vein, it was here, common hepatic artery, gastro-duodenal artery, stamp of the splenic

vein, superior mesenteric vein, portal vein.

Our definition of subtotal distal pancreatotomy is where we cut the pancreas is in the area

with or with no cutting of the gastro-duodenal artery.

artery. It's not simple distal pancreatectomy. We call it subtotal pancreatectomy. We put

a drain in the area of the lesser sac for another couple of days, usually 48, 72 hours.

This is a final picture. This patient, I remind you that this patient underwent multiple laparotomies,

Total laparotomy for ganglion's cholecystitis and simultaneous hysterectomy and bilateral

saphingrophorectomy, laparotomy for iatrogenic perforation of the duodenum during endoscopic

ultrasound about six weeks prior to this surgery, and this is the final picture.

This is our incision, seven and a half centimeter, and two incisions, additional incisions.

This is one, the left subcostal area, and two is the epigastrium.

Okay? Thank you very much.

Thank you.

Any questions you have?

Yes, one question, please.

Really, I have no experience in laparoscopic pancreatic resection.

I try only two times for benign lesions,

but I have a big problem to perform the operative file

file and to recognize the real destructors. In your experience, is this really a problem

or the experience could be resolved, these problems?

Once again, what problem you mean?

The first problem is to perform a good operative fight.

Our impression indeed is that we have a good view and maybe a better view to find the section

of the tissues of the pancreas and the vessels in this area and the camel bile duct laparoscopically

rather than the open surgery.

We don't perform WIPL operation or pancreatodiadenectomy laparoscopically because of quite difficulties

of – to perform choledochal or hepatico-digenostomy, but for distal pancreatectomy or subtotal

and distal pancreatectomy either, we – our policy is to do it laparoscopically – pure

laparoscopically but in the cases of where we expect the many adhesions or large specimen to

be removed to do hand assisted laparoscopic surgery okay and the second question was that

i agree with you that the laparoscopic injection the dissection is a it's better than than open

surgery but really my question was to perform the operative file to have a good vision of the

all destruction and the difficulties to recognize the vascular structure it's for you really the

problem or not in your experience no no not not really not really not really and we have we we

We are able to harass the large amount and sufficient amount of lymph nodes when dissecting

the ciliac trunk, periodontal lymph nodes, the nodes around the spleen, so we don't see

any particular problem to do this surgery laparoscopically.

Of course, we don't have prospective randomized study of the patients which underwent laparoscopic

because open surgery but our preliminary opinion we have an experience of dozens of such surgeries

we don't waste time and it's possible to is good opportunity and good alternative to the

open surgery okay thank you you're welcome i i lost your images but i i don't know if you

you. Can you hear me again? Okay, our next presentation is laparoscopic splenectomy for

giant spleen. Although laparoscopic splenectomy for normal size spleen is already well established

as the gold standard procedure, the use of laparoscopy for massively enlarged spleens

is controversial due to the many anticipated technical problems. The recently introduced

devices for performing a hand-assisted procedure may be a partial solution for

these problems. You can see here a massive splenomegaly due to myelodysplasia

and the outline of the spleen was marked on the skin of the patient prior to the

procedure. We make an incision in the sub-xiphoid area of a 7-7.5 cm in

length and put in the device for the hand-assisted procedure. The procedure is

starting with the entrance to the lesser sac and division of the short gastric vessels.

You can see here that these are relative very, very large vessels in such huge size spleens.

You see that we use both endoclips and the harmonic scalpel to control these large vessels.

vessels. After dividing the entire short gastric vessels, we now approach the splenic artery

and we clip it without dividing it yet. This will reduce the blood flow into the spleen,

will reduce in some degree the size of the spleen and the bleeding tendency while performing

forming the rest of the base section. This is an accessory spleen that with the consultation

of the hematologist was left in the patient. Now, again, you see here some of the other

short gastric vessels and their size and also the polar vessels to the inferior pole of

of the spleen. One of the problems is traction of such a heavy, huge spleen. You see here

some of the device that we use. We use the back of our hand, we use other retractors.

This is a continuation of the dissection towards the upper pole of the spleen. And now, we

we are ready for the division of the splenic hilum.

Such big spleens normally have a very large splenic vein

and also an enlarged splenic artery.

To reduce the risk of bleeding

while we divide it with an endostapler,

we developed this very simple technique

of using the hand for tying the splenic hilum

prior to its division with the endostapler.

and you can see here that it's done fairly easily.

We put in a Vicryl No. 1 or No. 2 tie,

and this will reduce the risk of bleeding in case of a misfiring of the stapler

or in case that the vessels are too large for one take of the endo stapler device.

Now you see the endo stapling with a vascular cartridge, of course.

you see that the one firing was not enough to divide the entire hilum we had to use another

one and you see that a very minimal bleeding due to the previous time you see here now the tide it

was placed prior to the division now another problem with these large spleens is firm

attachments and fibrosis to the surface of the diaphragm and the retroperitoneum,

sometimes due to previous irradiation that these patients received, and this patient did receive

irradiation prior to this procedure. Once the entire spleen has been freed and mobilized,

another challenge is to put it in a specimen bag that is large enough. There are no commercial

bags that are large enough for such big spleens this why here we used a standard

thick nylon bag and this is a time-consuming tedious procedure but

finally because of the nylon that's very smooth we managed to put in the spleen

and through the opening of the hand port the edges of the bag are being brought

out and now morcellation with instruments and finger morcellation is

being performed as you see here this also takes time but as you can see it's

done fairly easily we did some partial reconstruction of this large spleen as

you can see here we put all the big parts together the weight of this spleen

was 3.2 kilos, and now hemostasis is being achieved with the use of a laparoscopic argon

beam coagulator device. You can see that it's used here. We also use Avitan or Surgicel,

and we place two JP drains. You see here the abdomen after the completion of the procedure,

and this is the incision for the hand port.

Can you hear us?

We hear you, you can go ahead, thank you.

Okay, so what we will show you now, this is Dr. Reisman again,

and we will show you now a short video of a laparoscopic distal pancreatectomy

with spleen preservation for a small intrapancreatic tumor.

This is a 58-year-old patient who had a mixed solid cystic tumor in the proximal body of the pancreas

Due to the benign look of the tumor, the patient was offered a distal pancreatectomy with spleen preservation.

Can you hear the voice?

The lesser sac was entered using the harmonic scalpel.

We find it a very efficient instrument in the control of the small intestine.

Hello, we hear you. Go ahead, please.

Okay.

Hello?

Yes, we hear you well.

Yes. Do you hear the voice of the video?

Do you hear and do you see the video?

Arposcopic ultrasound is a crucial instrument in any pancreatic operation,

not only to .

Hello, Professor Rasmus, can you hear me?

Yes, I can hear you.

Okay.

Can you see the video?

Yes, welcome back in room.

I can see very well, thanks.

Thanks.

OK.

If you have any questions, I can stop it

and answer the questions.

What we saw until now is the intraoperative ultrasound

to locate the lesion, because this

was an intrapancreatic lesion.

And we decided to do a spleen preservation in this case.

And now we are trying to separate the vessels,

the sphenic vessels, from the body of the pancreas.

We are now on the dorsal border of the body of the pancreas and slowly we'll separate

the vessels from the body of the pancreas.

This is the splenic vein in the ventral area and this is again the dorsal area and we take

here the splenic vein and the splenic artery together.

Okay.

Okay, okay. You are again with us.

Okay. This is one of the branches of the vein and the artery going into the pancreas that we divide.

Sometimes we can get some bleeding, and we have to be very careful with this dissection

because of the many branches that are going from the splenic vessels into the pancreas.

Now we are preparing for the division of the pancreas,

and we have to make sure that we are away from the lesion.

And you see here the intraoperative ultrasound.

This is the tumor here.

So we know that if we will transect the pancreas over here, this will be okay.

Again, the intraoperative ultrasound is crucial here for this type of operation

because the tumor is a very small one and intrapancreatic we almost always use

the endo GIA stapling device as you see here with vascular cartridges and now we

do the dissection towards the tail of the pancreas of the spleen on the left

side you see the splenic vein some more branches that have to be divided

Although not proven, a fibrin-glued stapler line of the pancreatic stump here

and a JP closed suction replaced in about 20% of patients,

we had a controlled discharge on the false operative.

Can you hear us?

Yes. Just a moment. I speak with a colleague for the question. Just a moment.

Okay.

Hello.

Yes.

Hi.

Hello.

My name is Grandi. I have just a question about what is your experience about fine needle agobiopsy? I mean, preoperative.

What about the patient? I'm so sorry, I was not able to take a look at your procedure because we are following several screens.

But I'm really curious about the fine needle lago biopsy. Do you normally use it?

Well, we normally use it only if this is a cyst that we want to check the fluid for tumor markers like CEA and cytology.

But if it's a solid lesion, we normally don't take, as a routine, an FNA biopsy.

And the reason is that I think we should all agree that solid tumors of the pancreas, most of them need to come out anyway.

And the other problem is that we had several cases that developed hemorrhage and pancreatitis following the FNA.

a so in my mind I think it's not worth it and normally we will get an endoscopic ultrasound

a CT sometimes an MRI but not an FNA is a routine thank you thank you so much we have another case

case of a distal pancreatectomy with splenectomy. And this was a larger tumor. So we don't need

to do the ultrasound. And we will show it to you now. Can you see us? Yes, we are with

too. Okay, so you see here it's a larger tumor. This was a neuroendocrine tumor in the tail of

the pancreas. And we see here the tumor very clearly, unlike the previous case where we had

to use the ultrasound. And due to the size of this tumor, for oncological safety, we decided

We decided to do a distal pancreatectomy with splenectomy and not to try to save the spleen.

And as the previous case, the initial steps are entering the lesser sac and dissecting the pancreas out of the ventral side.

And we always use this maneuver to facilitate the retroperitoneal dissection.

we pass a Penrose drain or a vessel loop underneath the pancreas body with the splenic vessels together.

And this way we can do a better retraction of the pancreas and separate it from the retroperitoneal attachments

and then separate it from the splenic vessels so we can divide the splenic vessels with the pancreatic body.

This is the splenic vein that is being divided now between clips,

and this is the pancreatic body using the endogia, a vascular cartridge,

and now this is another firing due to the size of the pancreas.

This is always a little bleeding that is, in most cases, it will stop on its own.

But if needed, we can use some hemostatic lips on the staple line or argon beam coagulation

that is also very efficient for stopping any bleeding from the pancreas.

You see here the laparoscopic probe of the argon beam.

I think it's demonstrated very nice and this is again is the tumor we can see that we have good

margins and what you see here is that we are actually very close to the pancreatic neck we

finish the dissection with the spleen and this is all going into a specimen bag and we will show you

the continuation of the other video that shows another case which also has a similar tumor but

this one was really a subtotal pancreatectomy because you see here the tumor

was actually in the pancreatic neck between the head and the body and this is why the dissection

here has to be on top of the superior mesenteric vein this is what you see here we are going along

the superior mesenteric vein and portal vein. This is the mid-colic vein here on the right side. This

is the mid-colic vein and this is the SMV. This is the same dissection as we do for the Whipple

procedure. And here also we use a little thread or a vessel loop for attraction and lifting the

the pancreatic neck above the superior mesenteric vein.

So you see here again the superior mesenteric vein

and the pancreatic neck being retracted upwards.

This is on the right side a tumor, it is well seen.

We don't need an ultrasound here.

And this is the division of the pancreatic neck,

very close to the head and just on top of the SMV

and portal vein that you will see in a minute.

And you see here, very nice demonstrated,

this is the splenic vein on the right side.

And we have to take, in most of the cases here,

also the gastroduodenal artery.

And this is now the splenic artery that will be divided.

Excuse me, this is the splenic vein first,

and the artery will be divided later.

You see here the splenic vein taken down also

by the endogia and you see on the left side again the super mesenteric vein this is the

stump again the super mesenteric vein the stump of the splenic vein and again we use a vessel loop to

retract the rest of the body and the tail of the pancreas out of the of the retroperitoneal

attachments and once everything is mobilized including the spleen we can take it out using

the specimen bag we have to do a small incision to retrieve the specimen and you see here the tumor

you see that we have good margins of normal pancreas a fairly large tumor here taken out

completely with the spleen altogether as I said this was a neuroendocrine tumor and due to the

size this was a distal pancreatectomy with splenectomy this is the incision that we use

to retrieve the specimen and this is the abdominal wall after the procedure do

you have any questions about this case no no question no questions I can see

that I can see only that we have a very very nice images really it seems easier

to perform this technique did you never have a problem with hemorrhages or

bleeding and on someone do you convert some some patients we yes we had our

conversion rate is about 7% of cases until now we have over 60 cases done the

The conversion rate is about 7%.

And the main reason for conversion is bleeding.

The bleeding is either from one of the vessels

or from the spleen when you do a distal pancreatectomy

with splenectomy.

And what we are doing now is once we

have bleeding from the spleen, we ligate the splenic vessels

at the splenic hilum.

And this way, the spleen stops bleeding,

and we can continue the operation without a problem.